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Surgical closure of the lining of the abdominal cavity versus no closure for reducing wound complications after operations unrelated to childbirth

The peritoneum is the inner lining of the abdomen (tummy). After surgery, when closing the abdomen, some surgeons stitch the peritoneum together because they think this increases the strength of the wound. Others do not stitch the peritoneum together because they think it is unnecessary, increases operating costs through use of additional stitching material, increases operating time, and may increase pain. So, whether to close the peritoneum, and method of closure (continuous running stitches versus interrupted stitches) are controversial in operations not related to childbirth. We addressed these controversies by performing a thorough search of the medical literature for trials that compared closing and not closing the peritoneum after abdominal operations not related to childbirth. We included only randomised controlled trials without limiting trials according to language or year of publication, or number of participants in the study. Two review authors independently identified the trials and extracted information.

We identified five trials involving 836 participants who had open abdominal operations. Peritoneal closure was done in 410 participants and not done in 426. All trials had a high risk of bias. Only one trial reported the proportion of participants who died up to one year after the operation, and there was no significant difference between the closure and non-closure groups. Three trials reported major wound breakdown (burst abdomen), which requires emergency surgery. Overall, 10/663 participants (1.5%) developed burst abdomen, with no significant difference in proportions between the two groups. Three trials reported minor wound breakdown (incisional hernia), that may require surgery. Overall, 17/663 participants (2.5%) developed incisional hernia; again there was no significant difference between the two groups.

None of the trials reported on important outcomes, such as quality of life; the occurrence of intestinal obstruction (caused by intestines sticking to themselves and the abdominal wall (adhesions)); or the proportion of participants who had surgery to fix incisional hernia or adhesions. Only one trial reported length of hospital stay, and showed no significant difference between the groups, but did not include readmissions in its calculations. There does not appear to be any evidence for a short-term or long-term advantage in peritoneal closure in operations not related to childbirth. However, the trials were at high risk of bias, which can lead to false conclusions. Interestingly, our findings are similar to those of another research group who performed a similar review for operations related to childbirth.

Authors' conclusions:

There is no evidence for any short-term or long-term advantage in peritoneal closure for non-obstetric operations. If further trials are performed on this topic, they should have an adequate period of follow-up and adequate measures should be taken to ensure that the results are not subject to bias.

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Background:

There is no consensus regarding whether the peritoneum should be closed or left open during non-obstetric operations involving laparotomy. Neither is there consensus about the method of closure of the peritoneum (continuous suture versus interrupted suture). If closing the peritoneum could be omitted without complications, or even with benefit for patients, this could result in reductions in the cost of abdominal operations by reducing both the number of sutures used and the operating time.

Objectives:

To compare the benefits and harms of parietal peritoneal closure compared with no parietal peritoneal closure in patients undergoing non-obstetric abdominal operations.

We included only randomised controlled trials (RCTs) comparing peritoneal closure with no peritoneal closure in patients (adults and children) undergoing non-obstetric abdominal operations. All relevant RCTs irrespective of language, publication status, publication year, or sample size were included in the analysis.

Data collection and analysis:

Two review authors independently identified trials and extracted data. We calculated the risk ratio (RR) with 95% confidence intervals (CI) for comparing the binary outcomes between the groups, and mean difference (MD) with 95% CI for comparing the continuous outcomes. We performed the meta-analysis using both a fixed-effect model and a random-effects model. Intention-to-treat analysis was performed whenever possible.

Main results:

Five trials involving 836 participants randomised to peritoneal closure (410 participants) and no peritoneal closure (426 participants) were included in this review. All the trials were at high risk of bias. All the trials included participants undergoing laparotomy (open surgery). Four of the five trials used catgut or chromic catgut for peritoneal closure. Three trials involved vertical incisions and two trials involved transverse incisions. None of the trials reported 30-day mortality. There was no significant difference in the one-year mortality between the two groups (RR 1.11; 95% CI 0.56 to 2.19) in the only trial that reported this outcome. The only serious peri-operative adverse event reported was burst abdomen, which was reported by three trials. Overall, 10/663 (1.5%) of participants developed burst abdomen. There was no significant difference in the proportion of participants who developed burst abdomen between the two groups (RR 0.71; 95% CI 0.22 to 2.35). The same three trials reported the proportion of participants who developed incisional hernia. Details of the follow-up period were only available for one trial, and so we were unable to calculate the incidence rate. Overall, 17/663 (2.5%) of participants developed incisional hernia. There was no significant difference in the proportion of participants who developed incisional hernia between the two groups (RR 0.92; 95% CI 0.37 to 2.28). None of the trials reported quality of life; the incidence rate of, or proportion of participants who developed, intestinal obstruction due to adhesions; or re-operation due to incisional hernia or adhesions. Only one trial reported the length of hospital stay, and this trial did not include readmissions in its calculations. There was no significant difference in the length of hospital stay between the two groups (MD 0.40 days; 95% CI -0.51 to 1.31).

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